Healthcare Provider Details

I. General information

NPI: 1205804432
Provider Name (Legal Business Name): OKALOOSA WALTON UROLOGY PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 01/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1112 HOSPITAL RD UNIT A
FORT WALTON BEACH FL
32547-6655
US

IV. Provider business mailing address

1112 HOSPITAL RD UNIT A
FORT WALTON BEACH FL
32547-6655
US

V. Phone/Fax

Practice location:
  • Phone: 850-682-6333
  • Fax:
Mailing address:
  • Phone: 850-682-6333
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State

VIII. Authorized Official

Name: HELEN MCCOY
Title or Position: BILLING MANAGER
Credential:
Phone: 850-682-6333